Increase In Total Use Research Articles

Use of natural environments is associated with reduced inequalities in child mental wellbeing: A cross-sectional analysis using global positioning system (GPS) data

Exposure to natural environments may benefit child mental wellbeing whilst offering a lever to reduce health inequalities. However, understanding of these relationships is limited by evidence from indirect measures of exposure. We objectively measured children’s direct use of natural environments—and use in low or high physical activity (PA) states—and associated this with their mental wellbeing. We then examined moderation by sex and household income.Using global positioning system and accelerometry data from children (n = 640), we measured mean daily time in natural environments (‘total use’), which we stratified by PA level as ‘passive use’ (sedentary and light PA) and ‘active use’ (moderate and vigorous PA). Logistic regression associated exposures with dichotomised Strengths and Difficulties Questionnaire outcomes (internalising difficulties; externalising difficulties; prosocial behaviour), with interactions to examine moderation.A 10-minute increase in total use was associated with 10.5 % lower risk of abnormal internalising outcomes (OR: 0.895; 95 % CI 0.809, 0.990), and 13.2 % lower risk of abnormal externalising outcomes (OR: 0.868; 95 % CI 0.776, 0.990). This suggests that ∼ 60 min of daily total use was associated with 50 % lower risk of abnormal internalising and externalising outcomes. The relative effects of passive and active use were equal, but their associations were moderated by income independently for specific outcomes. For externalising outcomes, the risk of abnormal scores in lower-income children reduced as passive use increased (P = 0.027) but remained constant for higher-income children. For prosocial outcomes, the likelihood of normal scores increased with active use in lower-income children, but not higher-income children (P = 0.005). Sex did not moderate these associations.The findings suggest that targeted interventions supporting disadvantaged children to use natural environments could help address inequalities in mental wellbeing. Further, the moderated associations with types of use suggest the equigenic effects of natural environments may operate through multiple pathways.

Implementation of an electronic medical record order set with an opt-out rule increases utilization of ultrasound enhancing agents with transthoracic echocardiography

Abstract Background Use of ultrasound-enhancing agents (UEA) decreases the frequency of non-diagnostic transthoracic echocardiography (TTE) studies and improves accuracy for identification of potentially life-threatening conditions. However, several logistical barriers have led to UEA underutilization, including the need for a separate order for UEA in electronic medical records (EMR). We sought to determine the impact of implementing an EMR order set on utilization of UEA at the echocardiography laboratory of a tertiary care center. Methods EMR order for all TTE studies (complete, limited) was modified to include the use of UEA by default with an "opt-out" option for ordering physician when UEA is deemed unnecessary. During study performance, sonographers determined the need for UEA use and utilized existing order to dispense perflutren protein-type A microspheres to complete the examination. Internal policy for UEA use was developed in keeping with Intersocietal Accreditation Commission recommendations. We compared rates of UEA utilization 10 months before and after the implementation date (March 2022) for the new EMR rule. Results A total of 10,666 TTE studies were performed prior to, and 11,406 studies after the implementation of the new EMR rule. Of those, 54.3% were performed in outpatient setting, 12% in ICU, and the rest in non-ICU inpatient setting. Prior to the EMR rule implementation, UEA was used in 10% of total studies, 6.0% of outpatient studies, 11.2% of non-ICU inpatient studies, and 24.2% of ICU studies. Following the implementation of the new rule, UEA utilization increased significantly, including 89% increase in total use, 90% increase in outpatient setting, 129% in non-ICU inpatient setting, and 48% increased use in ICU (Figure). No adverse events were reported with UEA during the study period. Conclusions The implementation of a standing order in EMR, including default use of UEA with an "opt-out" option facilitates sonographer-driven use and administration of UEA across all patient care settings. While this approach was safe and significantly increased UEA utilization, whether it would translate to improvement in clinical outcomes or hospital length of stay requires further studies.Impact of EMR rule on UEA utilization

Use of sedating medications around nursing home admission in Denmark.

To examine use of sedating medications around the time of nursing home admission in Denmark. We conducted a register-based drug utilization study, describing patterns of commonly used medications with sedative effects leading up to and after nursing home admission using data from 94 Danish nursing homes between 2015 and 2017. We identified 5179 residents (median age 84 years, 63% female) and described monthly incidence and total use of benzodiazepines (BZDs), Z drugs, mirtazapine/mianserin, quetiapine, promethazine, and melatonin. The proportion of unique users of sedating medications was similar before and after admission (42% before vs. 40% after) despite an increase in total use after admission. The overall incidence of sedating medications peaked in the 6 months before and 6 months after admission (peaking at 4.6 per 100 person-months 1 month after admission). The most commonly initiated medications were mirtazapine/mianserin, followed by BZDs and Z drugs. Total use of sedating medications increased leading up to admission (peaking at 1001 defined daily doses per 100 residents per month 1 month after admission) and decreased gradually after admission. Sedative medication initiation increases sharply leading up to admission in Danish nursing homes. Mirtazapine/mianserin is a commonly used agent in nursing homes, despite limited evidence on benefits and harms. Efforts to promote rational use of these medications in nursing homes remain warranted.

The Association Between High and Unnecessary Antibiotic Prescribing: A Cohort Study Using Family Physician Electronic Medical Records.

Approximately 25% of outpatient antibiotic prescriptions are unnecessary among family physicians in Canada. Minimizing unnecessary antibiotics is key for community antibiotic stewardship. However, unnecessary antibiotic prescribing is much harder to measure than total antibiotic prescribing. We investigated the association between total and unnecessary antibiotic use by family physicians and evaluated inter-physician variability in unnecessary antibiotic prescribing. This was a cohort study based on electronic medical records of family physicians in Ontario, Canada, between April 2011 and March 2016. We used predefined expected antibiotic prescribing rates for 23 common primary care conditions to calculate unnecessary antibiotic prescribing rates. We used multilevel Poisson regression models to evaluate the association between total antibiotic volume (number of antibiotic prescriptions per patient visit), adjusted for multiple practice- and physician-level covariates, and unnecessary antibiotic prescribing. There were 499 570 physician-patient encounters resulting in 152 853 antibiotic prescriptions from 341 physicians. Substantial inter-physician variability was observed. In the fully adjusted model, we observed a significant association between total antibiotic volume and unnecessary prescribing rate (adjusted rate ratio 2.11 per 10% increase in total use; 95% CI 2.05-2.17), and none of the practice- and physician-level variables were associated with unnecessary prescribing rate. We demonstrated substantial inter-physician variability in unnecessary antibiotic prescribing in this cohort of family physicians. Total antibiotic use was strongly correlated with unnecessary antibiotic prescribing. Total antibiotic volume is a reasonable surrogate for unnecessary antibiotic use. These results can inform community antimicrobial stewardship efforts.

Points of agreement and difference: A rejoinder to Fischer et al.

Excerpt: The reply by Fischer, Rehm, and Crepault (2016) to my critique (Kalant, 2016) of their proposals (Crepault, Rehm, & Fischer, 2016) for cannabis legalization has helped to clarify the issues in this debate by making clearer the points of agreement and of continued disagreement. We agree on the following:•though not the most dangerous of drugs, cannabis can nevertheless cause serious physical and mental harm to some users, especially young ones•application of criminal sanctions against those charged solely with possession for personal use causes harm disproportionate to their offence, but only a small fraction of cannabis users in Canada are thus affected•control policy should be based on public health considerations, including prevention or minimization of cannabis-induced harm to the health of its most vulnerable users•for public health purposes it is important to know the number of users engaged in heavy, potentially harmful, use•increasing government revenue by taxation should not be a primary purpose•the policy should include research on more effective methods of preventive education, and on monitoring the consequences to society of the adopted policy•formulation of good policy requires both sound, objective knowledge about the matters at issue and value judgments that permit choice of the option yielding the greatest good and least harm. Fischer et al. (2016) reject decriminalization as incomplete and counterproductive policy, yet in arguing that liberalization of the law does not carry risk of major lasting increases of cannabis use they cite only evidence based on decriminalization, not on full legalization (e.g. Hughes & Stevens, 2010; Room, Fischer, Hall, Lenton, & Reuter, 2010). They do not discuss evidence concerning the extent of use in Colorado after full legalization, including that which appears to show a sharp increase in current use (RMHIDTA, 2016) and that which appears to show only a small increase (from 19.7% current use in 2013 to 21.2% in 2015) (Healthy Kids, 2015). Neither do they discuss young people’s anticipated changes in their own use after legalization (Palamar, Ompad, & Petkova, 2014), or the claim (Shi, Lenzi, & An, 2015) that use by adolescents – though only by girls, not by boys (Rogeberg & Stevens, 2016) – was higher in countries with the most liberalized laws. Fischer et al. thus offer no evidentiary basis for their contention that legalization would probably not seriously or lastingly increase use. Although we agree on the greater importance of dangerous rather than total use, it must be noted that Fischer et al. (2016) do not discuss the evidence concerning the relation between the two. While they are not always linked, the two have varied in tandem in most of the cases studied, both for alcohol and for cannabis (CANYS, 2009; Hughes et al., 2014; RMHIDTA, 2016; Rose & Day, 1990; Salomonsen-Sautel, Min, Sakai, Thurston, & Hopfer, 2014; Schmidt & Popham, 1978; Skog, 1985), in apparent compatibility with the single-distribution theory (Rossow, Makela, & Osterberg, 2007). Therefore possible increases in total use after legalization of cannabis would offer at least a strong suggestion of what is likely happening to level of harmful use. My statement (Kalant, 2016) that if we lack important knowledge about fundamental questions that is needed to permit a meaningful cost-benefit assessment of policy options, those policy choices can rest only on broader social values, ideals and hopes, is dismissed by Fischer et al. (2016) as “somewhat condescending”. To me it seems self-evident, with no element whatever of condescension. Values and ideals play a very important role in policy formulation (Kalant, 2010; Humphreys & Piot, 2012), and Fischer et al. themselves imply this when they refer to “social justice-based” policy, and to the symbolic value of the law as an indicator of the values of society. The point is simply that a policy based primarily on such values should not be called “evidence-based”. Fischer et al. (2016) repeat, again without presenting any evidence, the claim that decriminalization hinders, but legalization facilitates, the application of key interventions such as preventive education, early diagnosis and treatment. My critique (Kalant, 2016) presented evidence to the contrary, including the reports on the Portuguese decriminalization system (Hughes & Stevens, 2010, 2012; Stevens & Hughes, 2016) which Fischer et al. have themselves cited. School-based preventive education programs are already widely employed, but are not very effective (Porath-Waller, Beasley, & Beirness, 2010). Neighbourhood and peer group influences appear to be at least equally important in persuading adolescents to stop using cannabis (Pollard, Tucker, de la Haye, Green, & Kennedy, 2014). Intensive research... Language: en

Nephrology fellows show consistent use of, and improved knowledge from, a nephrologist-programmed teaching instrument

Teaching nephrology through a traditional classroom-based approach has significant time and place limitations. In the 21st century, these limitations are more prevalent and harder to resolve. Fortunately, online teaching instruments can overcome these restrictions. On this basis, we hypothesized that a nephrology-focused online teaching instrument, programmed and maintained by nephrology educators, would result in sustained use by, and improved test scores for, nephrology fellows. To test this hypothesis, we programmed and managed a 3-tiered Web-based teaching instrument based on the Blackboard platform. Nephrology fellows from Emory University, from the Classes of 2008-2010, were the primary subjects asked to use this instrument. We tracked their use of every teaching resource for 20 months. In addition we tested their knowledge of nephrolithiasis before and after using our interactive teaching module. Both the e-Library and Discussion forums showed increases in total use from years 1 to 2 (31% and 91% increases, respectively). When stratified by category or year in training, the changes in average monthly use of all online teaching resources were nonsignificant. Eight of 10 renal fellows showed increases in postmodule test scores (42.3% increase for the Class of 2009; 10.7% increase for the Class of 2010). Our results demonstrate sustained use in all 3 tiers of the online instrument. There was a significant improvement in knowledge after using the online module. The results indicate that nephrology educators can program sustainable online teaching tools that improve fellows' knowledge of nephrology.

The effect of re-siting a library

Report of a study undertaken by the library advisory team in the Department of Education and Science as part of their programme of monitoring and assessment. The Crumpsall District Library, Manchester, moved in July 1974 from the local shopping centre in Cheetham Hill to new accommodation in the Abraham Moss Centre. A study was made of variations in the provision and use of books in the library between 1972 and 1976. The move to the new building was accompanied by a considerable increase in total use, but a sharp reduction in visits by people aged 60 or more. Differences in the pattern of use were measured, but changes in the nature of the books and services provided made it difficult to isolate the effects of the change in location.